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Car Insurance Request Form

Select an option*

New Client

Existing Client

Completed By*

Contact Name*

Date of Birth*

Gender*

Main Driver?

Email*

Phone*

Garaging Address*

Garaging Method*

Vehicle Use*

Private Use

Business Use

Executive Use

Secondary Driver

Date of Birth

Gender

Vehicle 1

Insured Name*

Short answer*

Rego*

Cover Required*

Optional Cover

Hire Car Following Accident

Nil Excess Windscreen Cover

Roadside Assist (not available with all insurers)

Does the vehicle have any accessories?

Is the car under finance?*

Add second vehicle?

Have you made any claims in the past three years?*

Yes

No

Current Premium

Current Excess

Insurance Status*

Select a date*

Payment Frequency*

Any additional notes/concerns

PO Box 349, KYNETON VIC 3444

20 High Street, KYNETON VIC 3444

hello@macedonrangesinsurance.com.au

03 4411 2704

Important Information

Our Financial Services Guide

Insurance Brokers Code of Practice

Website by Techno Bird

Macedon Ranges Insurance Pty Ltd | ABN 65 672 507 191 | AR No. 1283072 Authorised Representative of PSC Connect Ltd ABN 23 141 574 914 AFS License No 344648.

We are a PSC Network Insurance Partner and part of the PSC Insurance Group, a publicly listed multi-national Insurance Broking company with global reach. We have the size and scale to help you protect your operations and assets by providing appropriate advice and the ability to leverage our scale with leading insurers, underwriting agencies, and access to the London insurance market. We benefit from knowledge across a broad range of industries so we can focus our efforts on understanding every customer, every policy and every risk, ensuring our clients have access to a wide range of insurance companies, a broad range of products, and highly-competitive industry pricing.

Disclaimer: The information provided on this website is for general information purposes only, and it is not a substitute for professional advice. You should always consider the PDS/Policy wording before making a decision. Coverage may differ based on specific clauses in individual policies. Refer to the FSG on our website or by requesting a copy for our services and remuneration details.

Macedon Ranges Insurance is a member of NIBA and endorse the Insurance Brokers Code of Conduct which can be found here.

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